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Exploring the diversity of FGM/C practices in Ethiopia: Drivers, experiences and opportunities for social norm change


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Exploring the diversity of FGM/C practices in Ethiopia: Drivers, experiences and opportunities for social norm change

  1. 1. Exploring the diversity of FGM/C practices in Ethiopia: Drivers, experiences and opportunities for social norm change March 2022 Domestic worker in Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020
  2. 2. Outline of Presentation 1 • FGM/C—Overview and Ethiopian context 2 •GAGE-Overview and sample and methods 3 •Findings on FGM/C 4 • Programming and policy implications 5 • Questions
  3. 3. 3 FGM/C Overview and Ethiopian context An adolescent girl, Ethiopia © Nathalie Bertrams / GAGE 2019
  4. 4. What is FGM/C and where is it practiced? • FGM/C is sometimes called ‘female circumcision’—but unlike male circumcision it has no benefits, only risks • FGM/C is practiced in dozens of countries—but is most common in Africa • FGM/C is not associated with any particular religious faith—it is practiced among communities that are Christian, Muslim and animists, and in the Ethiopian context also some adherents of the Jewish faith (Beta Israel) Source: National FGM Centre Female genital mutilation/cutting: all procedures involving injury to or removal of the external female genitalia for non-medical reasons
  5. 5. FGM/C includes a range of practices • Type 3, removal of the clitoris and inner and outer labia— known as infibulation • Type 4, all other procedures including scraping and nicking WHO and UNICEF delineate four types of FGM/C: • Type 1, removal of the clitoris and/or clitoral hood— known as clitorectomy • Type 2, removal of the clitoris and inner labia
  6. 6. FGM/C is common—but declining-- in Ethiopia At a national level, 65% of women between the ages of 15 and 49 have undergone FGM/C—down from 80% in 2000. Source: 2016 DHS Cohort analysis captures further improvement: Source: 2016 DHS Cohorts of women % cut % cut At a national level, 28% of girls aged 10-14 have undergone FGM/C • but this does not speak to incidence because many girls are cut in early adolescence.
  7. 7. Regional diversity is key to understanding FGM/C • Have different FGM/C incidence rates • Practice different types of FGM/C • Practice FGM/C on girls of different ages Amhara  62% of women  51% of girls 15-19  carried out soon after birth  clitorectomy most common Afar  92% of women  92% of girls 15-19  carried out in early childhood  infibulation is traditional Oromia  76% of women  46% of girls 15-19  carried out across childhood and early adolescence  mixed- primarily Types 1-2 Ethiopia’s political system is based on ethnic federalism. Its eleven regions are named after—and governed by—its largest ethnic groups. Because of this, regions:
  8. 8. Tracking changes in FGM/C type is fraught • There is debate about whether shifts to Types 1 (or 4) constitute progress in areas where Types 2 and 3 have been common. • Those advocating for ‘harm reduction’ correctly observe that Type 3 is most likely to result in death. The DHS classifies type of FGM/C differently than WHO: • Cut, no flesh removed (3%) • Cut, flesh removed (73%) • Sewn closed (7%) Many girls and women do not know what type of FGM/C they have undergone: • 18% of all women did not report/ know • 25% of girls 15-19 did not report/know • The international community has come down predominantly on the side of ‘no’. • Regardless, this is hard to track in Ethiopia
  9. 9. Overview of GAGE Adolescents in Afar, Ethiopia © Nathalie Bertrams / GAGE 2019
  10. 10. Gender and Adolescence: Global Evidence (GAGE): A longitudinal research programme in the Global South (2015-2024) By finding out ‘what works,’ for whom, where and why, we can better support adolescent girls and boys to maximise their capabilities now and in the future We are following 20000 adolescent girls and boys - the largest cohort of adolescents in the Global South
  11. 11. GAGE longitudinal research sample
  12. 12. GAGE Ethiopia research sites 3 regions: • Afar, Amhara, Oromia • plus Dire Dawa City Administration Research site selection based on: • Districts with among highest rates of child marriage as proxy for conservative gender norms (MOWCA, UNICEF and ODI, 2015) • Urban and rural sites • Food insecure and pastoralist sites as a proxy for economic poverty • Woreda-based mapping of all kebeles based on infrastructure and service availability (vulnerable/ less vulnerable) • Programming capacities of NGO implementing partners
  13. 13. An adolescent herding cattle, Ethiopia © Nathalie Bertrams / GAGE 2019 Findings
  14. 14. South Gondar, Amhara • 35% were cut • nearly all before their first birthdays Of younger cohort girls whose female caregivers reported: • 25% were cut • 70% of girls did not know when Of older cohort girls who self reported: • 61% took more than 3 days to recover • 12% took more than 7 days • 79% were cut by a traditional cutter Of all girls who have been cut: But some girls undergo Type 2 ‘On both sides there is a black part that is believed to hamper penetration.’ (father) Type 1 is most common ‘They cut the tip of the clitoris.’ (woreda level KI)
  15. 15. Most respondents see risks—some see advantages Most girls (74%) and caregivers (66%) report that FGM/C entails risks. Girls are less likely than caregivers to believe that: • FGM/C has advantages • FGM/C is required by religion • FGM/C should continue ‘It will be difficult for a man to have sex with her if she is not circumcised’ (kebele level KI) ‘FGM/C helps her vulva to stretch to make birth easier.’ (youth leader) ‘If a girl is not cut … she would become a slut.’ (woreda level KI) 74 11 12 12 66 28 26 17 0 10 20 30 40 50 60 70 80 Has risks Has advantages Required by religion FGM/C should continue % Older cohort girls Female caregivers of younger cohort girls
  16. 16. The dominant narrative is progress Schools spread the word—with cascading impacts ‘They teach us at school about harmful traditional practices …They are working very hard to teach us about FGM.’ (adolescent girl) ‘When there is an educated person in the family, that person tells [the others] that FGM/C is a harmful traditional practice and they need to avoid it. That person convinces the family and stops them from doing it.’ (woreda level KI) Health extension workers target women ‘Health extension workers are active in teaching about FGM … Starting from when they get pregnant, they have a follow-up with health extension workers. They teach them when to go for a check-up.’ (teacher) Religious leaders tailor messages carefully ‘Jesus was baptised with water, not circumcised.’ (Orthodox priest) ‘It is not possible to follow each rule and law provided by the book. This we should not follow.’ (Muslim sheik) Most participants report recent elimination ‘It is totally abolished now.’ (16-year-old girl) Progress is evident in individual families ‘I circumcised my older children. I have two young girls but they are not circumcised.’ (mother)
  17. 17. But subtexts suggest a need for caution • ‘There is no girl who is not cut.’ (adolescent girl) In remote communities, girls are still cut • ‘The practice of FGM/C is very difficult to sanction since it is practised by mothers/ grandmothers in a very private and hidden manner.’ (militia member) Women use ‘hidden practices’ • ‘There is no female genital mutilation … It is prohibited by the government … However, if their families [mother and father] have the skill, they circumcise their female children in a hidden way. … [His daughter] was circumcised by her mother … It was me that ordered my wife to circumcise our daughter.’ (father) Sometimes at men’s order • ‘These days they will be cut in health centres … the clitoris and the side flesh … If it is cut in the health centre, it doesn’t take long to heal … In the hospital they give painkillers and they apply ointments on the wound, that is why it recovers quickly.’ (mother) There is some evidence of medicalisation • ‘According to our criminal code of conduct, female genital mutilation is a criminal act … We are not seriously working on this aspect.’ (teacher) Kebele level officials are often not engaged
  18. 18. East Hararghe, Oromia Of older girls who self-reported: • 89% had been cut • 62% of girls had wanted to be cut at the time Of younger girls whose caregivers reported: • 65% of girls had been cut Of all cut girls: • Girls were cut at an average age of 9.6 years • 80% of girls were cut by a traditional cutter • Over 3/4 of girls took at least 3 days to recover • Nearly 30% of girls took at least 7 days to recover ‘Some are mutilated at a young age and others after growing up somewhat.’ (10-year-old girl) ‘They cut just the top part of it [the clitoris].’ (religious leader) ‘They sew your body and it stays until you get married.’ (15-year-old girl) • Girls are cut at different ages • Girls undergo different types of FGM/C • Girls also undergo FGM/C in different ways—some individually and some in a group ‘Everyone in the community do it.’ (15-year-old girl) • FGM/C is perceived as universal
  19. 19. Risks are poorly understood and attachment is strong • Girls are less likely to perceive risks than caregivers (30% vs 46%) • Girls are more likely to support continuation than caregivers (49% vs 37%) • Girls and caregivers believe: • FGM/C has advantages (~1/3) • FGM/C is required by religion (>2/3) ‘It is our culture … It is also a principle of Sharia [law] too.’ (social court member) 30 32 71 49 46 32 68 37 0 10 20 30 40 50 60 70 80 Has risks Has advantages Required by religion FGM/C should continue % Older cohort girls Female caregivers of younger cohort girls
  20. 20. Drivers are rooted in girls’ reproductive roles ‘I didn’t find girls who got married without being circumcised. It is shameful here not to be.’ (HEW) Girls cannot marry without FGM/C ‘During intercourse there is no way to insert the penis if the clitoris is not removed.’ (father) It is believed that sex is not possible without FGM/C ‘If the girl is not circumcised, she will not get pregnant.’ (younger boy) It is believed that pregnancy is not possible without FGM/C ‘The sexual desire of women who haven’t had FGM is inflated… We are farmers and engage in tiresome activities of farming… We cannot handle another responsibility of satisfying our wives because their sexual desire is heightened if they are not circumcised.’ (father) It is believed that FGM/C is required to lower girls’ and women’s sex drive
  21. 21. Despite pain, most girls want to undergo FGM/C Girls admit that they choose FGM/C ‘Daughters beg their families in order to get circumcised.’ (10-year-old girl) Girls are excused from housework and pampered by their mothers. • ‘They gave me milk and egg … They prepared for me rice and macaroni with sauce.’ (12-year-old girl cut at age 10) • ‘We prepared food and chicken and then the people come and give you money.’ (14-year-old girl cut at 12) Girls want to fit in with their peers • ‘There is an insult for girls who are not circumcised.’ (married 11-year-old girl) Girls want to show their peers they are old enough to attend shegoye dances • ‘They have to be first circumcised. It is after circumcision that a girl attends shegoye.’ (17-year-old girl) Girls acknowledge that FGM/C is painful ‘They will tie your hand and leg together and also cover your eyes. They also hold your mouth hard so that you don’t cry.’ (12-year-old girl) Why do girls want to be cut?
  22. 22. But parents make sure girls ‘choose’ correctly ‘It cannot be stopped … If we are not interested to be circumcised, our parents beat [us] and force us to be circumcised … We cannot decide. It is our families who force us to be circumcised.’ (17-year-old girl) ‘If she married without, they will cut her during aruza [honeymoon] ... If they cut you during aruza, the pain is huge. So it is better to have FGM long before getting married.’ (14-year-old girl) ‘The government has a huge plan to prevent FGM … but her mother never accepts it because she considers it as a big shame culturally … They will not be willing to spare their girls from undergoing FGM.’ (social court member)
  23. 23. Backsliding is increasing—and set to increase more ‘If we see it and hear about it, we will put them in jail.’ Officials proclaim progress ‘In the past, during our mothers’ time, they were prohibited to practice circumcision … Now, it’s open.’ (13-year-old girl) But girls report the reverse ‘You go to a health facility. You can deliver through an operation, for instance.’ (17-year-old girl) Awareness raising is falling flat ‘The kebele administrator takes money from people who circumcise their girls. He takes (for instance) up to 200 birr (~$4)… The administrator stopped now. People don’t even give him [the money] even if he asks now. They don’t listen to him now. They do the circumcision freely.’ (young woman) Fines are ignored ‘Girls do not listen to their families … They just go with boys … They go with boys to get married. In the past, we didn’t go after boys unless we were asked for marriage because we were circumcised.’ (grandmother) There are calls to resume more invasive types ‘There was a female teacher that used to register the names of parents who allowed girls to undergo FGM/C, but since there is no school, they cut girls and there is no one to question them.’(kebele level KI) Covid has complicated protection ‘Previously it was forbidden, but now they allow it.’
  24. 24. Zone 5, Afar Of older cohort girls who are self reporting: • 84% have been cut Of younger cohort girls whose mothers are reporting: • 92% have been cut Of all girls who have been cut: • Girls were cut at an average age of 1. 5 years • 78% took at least 3 days to recover • 17% took at least 7 days to recover • 67% of girls were cut by a traditional cutter ‘Up to now, there is no girl who is not circumcised ... all girls are circumcised.’ (19-year-old girl) FGM/C is effectively universal: • There is some variation in age—soon after birth to pre-school aged • Who cuts girls is shifting—primarily to make it more private ‘Previously, there were skilled elder women who made FGM, moving from home to home. However, now every mother practises FGM of her own daughter.’ (mother) ‘Though we know that female genital cutting harms our daughters, we are still practising it.’ (religious leader)
  25. 25. In more central communities, type is (probably) shifting ‘In previous times, we used to cut them deep. We even take some part from the side and then we sew it. But now we have learnt that this will have a problem at the time of giving birth. So we cut only the part called haram [forbidden by Islamic law].’ (mother) ‘Currently people cut only the tip of the girl’s clitoris, people stopped cutting the entire part of the inner of the girl’s genital organ from three directions.‘ (clan elder) Type 1 is replacing infibulation ‘We work with women doing it and give them alternative income opportunities. And we also organised a reward programme for champions who stopped doing it.’ (Justice KI) ‘I told my relatives if they try to practise it again, they would get imprisoned for 10 years, pay a 10,000 birr fine.’ (HEW) Because of officials’ efforts ‘Especially, the Sharia persons and religious leaders taught us to change the type of cutting and to use the ‘sunna’ type.’ (clan elder) ‘Muslim leaders tell us it is contrary to the Sharia and only slight cutting is allowed.’ (male community KI) And most especially because of religious leaders’ efforts
  26. 26. In more remote communities, stasis rules ‘What we are practising now is what we were practising previously.’ (clan elder) ‘Those circumcised girls’ legs will be tethered together using rope, to make the cut organ stick together and their organ will get narrower. They do not use any medical treatment to heal the wound, they use cultural treatment, and the wound will cure after a week or after two weeks … There is no sewing in our locality, the cut organ will be stitched up together with blood.’ (19-year- old girl) ‘There is no sanction or punishment because all people in this community accept that female genital mutilation is normal.’ (clan elder)
  27. 27. Advantages are perceived to outweigh risks • Just under half of girls and caregivers report that FGM/C has risks • Just over half of girls and caregivers report that FGM/C has advantages • More than two thirds of girls and caregivers believe that FGM/C is required by religion • Girls are more likely than caregivers to believe that FGM/C should continue ‘Girls would misbehave and be disobedient to their parents unless they were circumcised.’ (mother) ‘It is difficult to have sex with uncircumcised girls since the clitoris prevents the penis penetrating deep in the girl’s vagina.’ (14-year-old boy) 44 56 71 72 46 56 65 51 0 10 20 30 40 50 60 70 80 Has risks Has advantages Required by religion FGM/C should continue % Older cohort girls Female caregivers of younger cohort girls
  28. 28. Social pressure ensures compliance ‘We are also told that a father who didn’t circumcise his daughter is considered as lazy and we are also ordered not to get in the house of a man who didn’t circumcise his daughter because having a daughter who is not circumcised is considered haram.’ (clan elder) ‘I wouldn’t be happy if I wasn’t circumcised … Not being circumcised is haram.’ (15-year-old girl) ‘We are happy [to be cut] … They insult us by singing “their clitoris is longer like hala wolf ”.’ (17-year-old girl) ‘If a girl is not cut, she will be isolated by the people. So, the girls themselves agree to circumcision. They prepare themselves and ask the mother to do it. It is done based on family interest and the girl’s willingness.’ (mother) ‘It becomes risky to speak about stopping FGM among rural communities and they are afraid to teach about FGM as a bad practice because it has been a long-held traditional practice … For instance, there is a midwife working at Community B and she told us that the community laugh when she teaches about avoiding FGM.’ (woreda level KI) Girls comply to avoid exclusion Adults comply to avoid exclusion
  29. 29. Progress depends on religious leaders ‘We will never accept what the government law is saying.’ (clan elder) ‘We can change the practice only if we heard it from religious leaders. We do not stop because of meetings.’ (grandmother) ‘They taught us that it became a big sin if a female child died without being circumcised.’ (mother) Some religious leaders are actively promoting FGM/C The law pales beside religious authority Adolescents, in Afar Ethiopia © Nathalie Bertrams /GAGE 2018
  30. 30. Infibulated girls need support ‘Husbands use energetic efforts to dis-virgin [have sexual intercourse with] their wives.’ (clan elder) ‘Many girls cry during sexual intercourse.’ (married 17-year-old girl) ‘The organ that was connected during circumcision doesn’t allow her to give birth freely.’ (married 18-year-old girl) ‘Doctors are insulting girls during childbirth … They say that because we are circumcised, we are unable to labour … When we tell them there was nothing we could do about it, they reply, saying that we know nothing about giving birth because we are circumcised.’ (married 19-year-old girl) Sex is painful Giving birth is difficult and humiliating
  31. 31. Urban areas At a national level, the prevalence of FGM/C in urban areas is 54% (compared to 68% in rural areas) ‘ I know a teacher who forced her daughter to get cut. She used to teach us about harmful traditional practices and HIV and AIDS. She even goes to rural villages to raise awareness on this. I remember how shocked I was to learn this. I did not expect this from her. ‘ (17-year-old girl, Dire Dawa) • But GAGE urban areas are not all the same: • 19% in Debre Tabor (Amhara) • 29% in Batu (Oromia) • 46% in Dire Dawa • Girls growing up in urban areas are most often cut in rural areas over school holidays. Adolescents student, Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020
  32. 32. Donor and NGO efforts are broad…but challenges are large What efforts? • Community conversations about FGM/C and gender • Engagement with religious and clan leaders • Girls’ clubs • Engagement with mothers • Engagement with men and boys • Exposure to local champions • Education and alterative income for cutters Which actors? Examples include: • UNICEF-UNFPA • CARE • Pathfinder • Population Council • Action Aid • Save the Children • Plan • African Women Organisation • Islamic Relief Worldwide • KMG • Norwegian Church Aid Participant girls are ~ 25% more likely to know risks of FGM/C
  33. 33. Implications Adolescents, Amhara, Ethiopia © Nathalie Bertrams /GAGE 2020
  34. 34. Implications for policy and programming 1 • Address underlying gender norms through context-tailored approaches incl. working with religious leaders, parents, and adolescents—and addressing risks and perceived advantages. 2 • Raise awareness of the criminalization of FGM/C—considering transparently levied and bottom-up fines on a community-by-community basis and providing girls with uncut role models to counter peer pressure. 3 • Engage with health care providers to encourage their work with new mothers, prevent medicalization, and ensure that cut girls are treated sensitively. 4 • Adopt a long-term lens that recognizes that change is non-linear and that continuous pressure is required over time to prevent hidden practices and resurgence.
  35. 35. Questions An adolescent IDP girls, Ethiopia © Nathalie Bertrams / GAGE 2019
  36. 36. Contact Us WEBSITE TWITTER @GAGE_programme FACEBOOK GenderandAdolescence About GAGE:  Gender and Adolescence: Global Evidence (GAGE) is a nine-year (2015-2024) mixed- methods longitudinal research programme focused on what works to support adolescent girls’ and boys’ capabilities in the second decade of life and beyond.  We are following the lives of 20,000 adolescents in six focal countries in Africa, Asia and the Middle East.

Editor's Notes

  • Female genital mutilation/cutting: all procedures involving injury to or removal of the external female genitalia for non-medical reasons

    FGM/C is sometimes called ‘female circumcision’—but unlike male circumcision it has no benefits, only risks

    FGM/C is practiced in dozens of countries—but is most common in Africa—where it is practiced in 29 different countries

    FGM/C is not associated with any particular religious faith—it is practiced in several

  • WHO and UNICEF delineate four types of FGM/C:

    Type 1, removal of the clitoris and/or clitoral hood— known as clitorectomy

    Type 2, removal of the clitoris and inner labia

    Type 3, removal of the clitoris and inner and outer labia—where girls’ genitals are then fused together, leaving only a small hole for urine and menstrual blood, this is known as infibulation

    Type 4, all other procedures including scraping and nicking
  • The most recent DHS, which was fielded in 2016, found that 65% of women between the ages of 15 and 49 had undergone FGMC.

    This is down from 80% in 2000 and 74% in 2005.

    Cohort analysis of the 2016 DHS also shows progress.

    Adolescent girls between the ages of 15 and 19 were much less likely to report being cut than women over the age of 35—47% ad 75% respectively.

    The 2016 DHS also asked female caregivers about younger girls’ experiences with FGMC.

    At a national level, one-quarter of girls between the ages of 10 and 14 were reported as having been cut.

    This figure, however, does not speak to especially rapid progress in the most recent cohort.

    Many girls aged 10-14 will be cut in the next few years—before they turn 15.

  • Regional diversity is key to understanding FGM/C in Ethiopia.

    Because the country's 9 regional states were allocated to its largest ethnic groups, differences between regions largely reflect the country’s ethnic (and religious) variation.

    In Tigray, only 24% of women have undergone FGMC.

    In Somali that figure is approaching 99%.

    It is not only the incidence of FGMC that varies across region.

    There is also variation in type and the age at which girls are cut.

    In Amhara, for example, girls are cut in infancy and usually undergo clitorectomies.

    In Oromia, girls are often cut in childhood and early adolescence.

    In Afar, girls are also cut as infants and infibulation is traditional.
  • There is considerable debate as to whether shifts from infibulation to clitorectomies constitute progress.

    On the one hand, infibulation is far more likely to result in death—for girls and their future children—than are Types 1 and 2.

    On the other hand, counting shifts in type as progress are likely to make it more difficult to eradicate the practice.

    Evidence of this can be seen in the way FGMC continues unabated in Egypt—where the practice is now medicalized ostensibly to reduce the harm it causes girls.

    The international community has largely come down on the side of ‘no’—and does NOT view shifts in type as progress.

    The Ethiopian government is also working towards total eradication. FGMC is criminalized and the government has a costed plan for elimination by 2025.

    That said, the DHS is still capturing evidence about the type of FGMC being practiced in Ethiopia.

    It is doing so, however, in a way that does not line up with international convention.

    It delineates between cut with no flesh removed cut with flesh removed and sewn shut.

    Because it does not ask WHICH flesh—nearly all girls and women in Ethiopia fall into category two: cut with flesh removed.

    Critically, for tracking change over time, a large number of girls and women do not know how to describe the FGMC they have undergone.

    Of all women, 18% either did not know or did not report the type of FGMC they had undergone.

    Of all girls 15-19, that figures rises to 25%.
  • Gender and Adolescence: Global Evidence (GAGE) is a nine-year (2015-2024) mixed-methods longitudinal research programme exploring the gendered experiences of young people aged 10-19 years.

    GAGE aims to generate new evidence on ‘what works’ to transform the lives of adolescent girls and boys to enable them to move out of poverty and exclusion, and fast-track social change.

  • In Ethiopia, GAGE has completed both baseline and midline data collection.

    We are following two cohorts—a younger and an older—comprising 7,500 young people.

    At the time of midline data collection, the younger cohort was between the ages of 12 and 14. The older cohort was between the ages of 17 and 19.

    We are using mixed methods and in addition to our surveys with adolescents and their caregivers, have completed individual and group interviews with hundreds of adolescents, caregivers, community members, and service providers.

    GAGE is also running ongoing participatory research groups with 100 adolescent girls and boys.
  • In Ethiopia, we are working in three rural locations:

    South Gondar, Amhara
    East Hararghe, Oromia
    Zone 5, Afar

    We are also working in three urban locations:

    Debre Tabor
    Dire Dawa
  • Echoing the 2016 DHS findings, our research underscores the importance of recognising and embracing the diversity that surrounds FGM/C in Ethiopia.

    Across regions and communities, girls are cut at different ages and in different ways.

    Furthermore, while the drivers of FGM/C are, at the highest level, shared across the study locations, differences in how drivers are embedded in regionally variable religious beliefs and cultural practices are stark and speak to a need for carefully tailored elimination strategies.

    Because of the diversity that surrounds FGM/C in Ethiopia – especially at the regional level – our findings are organised here by region.
  • In South Gondar—there was a mismatch between what was reported by older cohort girls and what was reported by younger girls’ caregivers.

    This is because girls are cut in infancy and therefor do not always know whether and when they were cut.

    Female caregivers reported that 35% of younger cohort girls had undergone FGMC.

    Nearly all were cut in infancy.

    Type 1—clitorectomy– is most common in SG. But some girls also undergo the removal of the inner labia.

    Caregivers reported that most girls recovered in less than a week.

  • A large majority of older cohort girls and female caregivers in South Gondar were aware that FGM/C entails risks.

    The most commonly identified risks were difficulty giving birth and infection.

    In South Gondar, older cohort girls were quite unlikely to report that FGM/C has advantages (11%). Those that did reported that it could ease childbirth.

    Older girls were also unlikely to believe that FGM/C is required by religion (12%) or that it should continue (12%).

    Female caregivers of younger cohort girls were more likely to report that FGM/C has advantages (28%)—namely easier sex and easier childbirth.

    Caregivers were also more likely to believe that FGM/C is required by religion (26%) and should continue (17%).
  • In SG, the dominant narrative was progress.

    Girls, parents, community members, religious and traditional leaders, and government officials overwhelmingly spoke of how FGM/C is becoming less common over time.

    Recent progress was esp highlighted in large families—where older daughters had undergone FGMC and younger daughters had not.

    Awareness raising in SG is carried out in myriad venues.

    Adolescents are taught about FGMC at school—in health and civics curricula and also in girls’ clubs.

    While what adolescents are learning at school does not protect adolescent girls themselves—bc girls are cut in infancy—some adolescents are able to protect their younger sisters from undergoing FGMC and over time, as adolescents become parents, impacts are set to expand.

    Mothers are targeted by HEWs—who work with pregnant women to encourage them to eschew cutting their infant daughters.

    In SG, which is primarily Ethiopian Orthodox, religious leaders reported that they are framing messages carefully—matching what they think community members will most respond to.
  • Hidden behind reports of progress, however, there are many signs that FGMC remains far more prevalent than respondents report.

    In the most remote communities, adolescent girls report that nearly all girls are cut.

    Adults—when pressed—often agree and add that practices have simply moved underground in response to government messaging.

    Esp interesting are narratives about women’s responsibility.

    In some cases, it is clear that fathers really do prefer to end FGMC and mothers do not. Mothers are pushed into conformity by their own mothers and by other older women in the community.

    In other cases, fathers first claim that mothers are responsible—and then admit that they too support FGMC

    In SG, and only in SG, we found some evidence of medicalization. Community members have heard messages about the health risks of FGMC and have responded not by eliminating the practice—but by making it ‘safer’.

    Shifts such as these are the primary reason the international community is loathe to adopt a harm reduction strategy.

    We also found evidence of fatigue in SG. Local service providers and officials—esp in more remote communities—are simply tired of working to eliminate FGMC in the face of little progress.
  • In EH, we found that FGMC is far more common than it is in the Oromia region as a whole.

    Of older cohort girls, nearly 90% report being cut.

    Girls were cut, on average, shortly before their 10th birthdays.

    But this average hides variation. Some girls in EH are cut as toddlers and others in early adolescence.

    Respondents reported that in some communities—where there is more enforcement-- girls are cut when they are younger—because it is easier to hide FGMC when girls are not yet enrolled in school.

    The ceremonies attached to fgmc are also shifting to make the practice harder to detect. In some communities, girls are cut individually, at home, rather than in groups.

    Most girls in EH appear to undergo Type 1 FGMC—but type 2 is not rare and Type 3 exists.

    Most girls recovered in a week—but nearly a third required more than a week to heal.

  • Older cohort girls in EH were far less likely than their peers in SG to identify that FGM/C entails risks. Only 30% reported there were risks.

    Girls were most likely to identify infection and difficult childbirth as risks of FGMC.

    Older cohort girls in EH were far more likely than their peers in Amhara to believe that FGMC has advantages. Nearly half of girls reported that FGMC has advantages.

    Girls most often identified that FGMC improves girls’ behaviour.

    Mothers of younger cohort girls were more likely than older girls to report risks (46%).

    Mothers identified infection, difficult sex, and difficult childbirth as risks of FGMC.

    Mothers also reported that FGMC has advantages—namely improving girls’ behavior.

    In part because girls and mothers believe that FGMC is required by religion, they are more likely than those in SG to believe that FGMC should continue.

    Interesting, mothers are less likely to report that FGMC should continue than girls.

    Our qualitative data suggests this is because girls are likely more honest in their responses.
  • In EH, which is predominantly Muslim, respondents often began by explaining that FGMC is a religious mandate.

    However, narratives almost immediately shifted to how FGMC is necessary to control girls’ and women’s sexuality and allow them to fulfill their reproductive roles.

    Girls cannot marry without FGMC

    Girls cannot have sex without FGMC—because female anatomy precludes penetration.

    Girls cannot conceive without FGMC.

    FGMC makes childbirth easier because it helps the vulva to stretch.

    Critically—FGMC ‘tames’ women’s sex drives—which are perceived to be extremely high and more than men can satisfy.

  • Because most girls in EH are cut when they are in late childhood and early adolescence—there is more space for girls in that area to actively input into whether and when they will undergo the procedure.

    Our research finds that girls do not use this space to refuse.
    Indeed, girls quite commonly reported that they demand to be cut and that their parents sometimes put them off.

    Girls are not choosing FGMC blindly—they know they procedure is extremely painful.

    However, they do see the advantages as outweighing the disadvantages.

    Undergoing FGMC not only buys them time off of chores—which in EH occupy all of girls’ waking hours
    But it often buys them signs of affection from their mothers—which in EH are fairly rare

    Girls esp like that they are fed favored foods.

    Girls also want to undergo FGMC because they want to show their friends that they are growing up.
    In EH, there are cultural dances that are for adolescents only
    Girls generally have to undergo FGMC before they can begin to participate in these dances

    They also want to show their friends and the broader community that they are conforming to the social norms about femininity
  • Despite narratives about girls’ choosing FGMC of their own accord, the subtext in interviews indicates that if girls fail to conform, they will be forced.

    Mothers in particular are unable to bear the shame of having an uncut daughter.

    Girls added that if they fail to undergo FGMC in early adolescence—they will be cut during their honeymoon—when the pain will be far worse because they will be having regular sex.

  • While in SG the narrative is about progress over time, in EH there is largely the reverse.

    Although a few officials gave lip service to enforcement,

    in most communities, adolescents reported that while FGMC used to be hidden, now it is open.

    Young people reported that awareness raising messages are falling flat—bc they address only the risks of FGMC, which are considered unlikely and bearable in the context of more obvious advantages.

    They also reported that enforcement is non-existent. Even if officials tried to levy fines—they would be ignored.

    In EH, broader narratives about ‘girls’ choice’ are set to further complicate progress.

    Girls and parents in EH report that girls choose their lives.
    They choose to be cut.
    They choose to drop out of school.
    They choose to dance shegoye.
    They choose to marry.

    By framing FGMC as a choice that girls—and not parents—are making, it relieves parents of responsibility and makes enforcement more difficult.

    Beyond that, because parents are frustrated that girls are now ‘choosing’ their own marriage partners, where marriages used to be arranged by parents and elders, there are now growing calls to return to more invasive forms of FGMC as a means to better control girls’ sexuality.

    In EH, but not SG and Z5 (BC girls are cut as infants), the pandemic has complicated efforts to work with and protect girls from FGMC. Schools were closed for many months and teachers left town.
  • In Zone 5, FGMC is effectively universal.

    84% of older cohort girls and 92% of younger cohort girls’ mothers admitted that girls had been cut.

    Most girls were cut before they turned one, but some were cut in early childhood.

    Most girls (78%) recovered in a week, but a sizably minority took more than a week to heal.

    As in EH, who cuts girls is shifting—likely in response to government efforts to eradicate the practice.

    Although most girls are still cut by traditional cutters, a growing proportion are cut by their own mothers.
  • With the caveat that there are hints that respondents are reporting what they feel they should—to better align practices with the law—in more central communities narratives suggest that infibulation is being replaced by clitorectomy.

    Respondents highlighted the efforts of officials—who are raising awareness about the risks of infibulation and threatening fines

    But more importantly, they highlighted the efforts of religious leaders.

    Imams and sheiks are preaching that the Quaran forbids infibulation and requires only clitorectomy.
  • In more remote communities, most respondents reported only stasis.

    They admitted that they are still infibulating girls—with scar tissue rather than sewing—and that there are no efforts to promote change because officials as well as community members see the practiced as completely normal.
  • In Zone 5, just under half (46%) of older cohort girls and caregivers of younger cohort girls report that FGM/C carries risks.

    They were most likely to identify difficulty in childbirth, infection, bleeding, and difficulty having sex.

    Just over half (56%) of girls and caregivers reported advantages to FGM/C.

    They were mostly likely to identify improving girls’ behaviors and easier childbirth.

    Similar to EH, in Z5 it is largely agreed that FGM/C is required by religion. 71% of girls and 65% of female caregivers report that it is required.

    Also similar to EH, girls are more likely to report that FGMC should continue than mothers. 72% of girls reported they believed FGM/C should continue vs 51% of mothers.

    Again, we suspect this is because adults are more reticent about reporting the truth.

  • While the type of FGMC practiced in more central communities may be changing, respondents are practically unanimous that efforts to eliminate the practice entirely are doomed to fail.

    As in EH, FGMC is so universal that parents and girls would be socially excluded if they failed to comply.

    While in SG, HEWs actively work with pregnant women and new mothers to discourage FGMC, officials in Z5 admitted this is all but impossible.

    HEWs who try to discuss the risks of FGMC are often publicly humiliated.
  • In Z5, while there are religious leaders who are promoting clitorectomy rather than infibulation, religious leaders are still fundamentally promoting FGMC as a religious mandate.

    Because of this—community members report that government messages about eradication are irrelevant.

    National law is felt to be especially irrelevant—bc it pales in comparison to God’s law.
  • Older girls, who are more likely to have been infibulated and to be married and mothering, report that alongside efforts to eliminate FGMC there needs to be more support for girls who have been cut.

    Quite a few reported excruciating sex.

    Several husbands admitted that it had been hard to have sex with their wives, especially in the early weeks of marriage.

    One man reported that he had not been able to bear his wife’s screams—and instead asked a friend to ensure his wife was ‘dis virgined’.

    Infibulated girls also reported that they were treated badly by health care professionals during childbirth—which was already difficult given damage to their bodies.

    Several said they had been insulted and called backwards.
  • We are finding that while FGMC is less common in urban areas than in rural areas—it is important that urban areas are not left out of programming. The same forces that drive FGMC is rural areas often also do so in urban areas.

    Equally importantly, we are finding that urban areas are not a monolithic whole—they reflect the regions in which they are located.

    Of the urban areas in which GAGE is working, Debre Tabor—which is in South Gondar—has the lowest rate of FGMC (19%).

    Rates in Dire Dawa, which is an independent city located on the border of Oromia and Somal, are far higher (46%).
  • Donors and international and national NGOs are heavily engaged in working to end FGM/C in Ethiopia.

    After decades of experience, programming recognizes how deeply FGM/C is embedded in social norms and tends to take a multifaceted approach that often starts with engaging communities in conversations about the perceived advantages and disadvantages of FGM/C.

    This has been found to work far better than top-down messaging.

    The support of religious and traditional leaders has been found to be especially important—because they can help communities understand that FGM/C is not mandated by religious texts.

    Programming often also uses different modalities to reach different actors.

    Girls are empowered in girls’ clubs—that can teach them about the risks of FGM/C but more critically support the development of their voice and agency to resist pressure from their parents and peers.

    Mothers and fathers—and sometimes the older boys and young men who will be girls’ husbands—are usually targeted in single sex groups. Boys and men are sometimes found to be powerful advocates against FGM/C.

    Exposure to local champions—girls and women who have not been cut and who are considered successful—are especially important to persuading women and girls, who know they will bear the brunt of defying social norms.

    Where traditional birth attendants cut girls soon after birth, there are also efforts to educate TBAs about the risks of FGM/C.

    These are sometimes paired with schemes to help TBAs and other traditional cutters replace the income they earn from cutting.

    GAGE is partnered with two efforts to eliminate FGM/C in Ethiopia.

    Act With Her is funded by the GATES Foundation and implemented by Pathfinder and Care in Amhara, Oromia, and Afar.

    AWH is aimed at young adolescents and their caregivers and communities. It hopes to improve girls’ access to education, sexual and reproductive health, bodily integrity, voice and agency, psychosocial wellbeing and economic empowerment.

    Because reducing FGM/C is a key part of improving girls’ bodily integrity—efforts include direct attention to this topic.

    AWH is a multifaceted intervention that is designed as a 4 arm RCT.

    The first arm is clubs and education for girls.
    The second arm adds clubs and education for boys and girls’ caregivers.
    The third arm adds community conversations and efforts to strengthen local education and health systems.
    The fourth arm adds asset transfer for girls.

    GAGE will be tracking AWH impacts over time—but early results suggest the programme is helping girls learn about the risks of FGM/C. Across regions, participant girls were approximately 25% more likely than non-participant girls to identify that FGM/C has risks.

    GAGE is also evaluating a programme funded by Irish Aid and implemented by Save the Children in Afar and Somali.

    This programme—which is aimed specifically at eliminating FGM/C and child marriage--is just launching and is similarly multifaceted.

    It includes girls’ clubs, educational stipends for girls, radio listening groups and economic empowerment programming for mothers, efforts to engage boys and men, community conversations that include religious leaders, and efforts to build local capacity.

    Our evaluation of AWH—as well as other evaluations of other programmes—suggests that it will be challenging to eliminate FGM/C in the government’s time frame.

    Imparting knowledge about the risks of FGM/C is comparatively easy. Changing attitudes and practices is far harder, because even when people understand risks, they still perceive advantages. In communities where cutting is endemic—and required for marriage—the risks of FGM/C itself pale in comparison to social exclusion.

  • Donors and NGOs should work with community leaders to address underlying gender norms through context-tailored approaches

    Eliminating FGM/C will require working with parents and broader communities (to protect the youngest girls) and adolescent girls and boys (to protect older girls as well as to expedite generational change).

    Messaging about FGM/C should be balanced and address both its perceived costs and perceived benefits.

    In communities where FGM/C is believed to be required by religion, it is vital to work with religious leaders to disseminate messages that clearly state the reverse – teaching community members that FGM/C is not required by religion.

    Messaging for parents should be provided through parent education courses, women’s associations and health extension workers, carefully timed to address community practices

    Messaging for communities should include community conversations, led by religious leaders where possible, as well as using mass media, especially radio.

    Adolescents, including those in urban areas, should be targeted for FGM/C education through the school curriculum and also through participatory school clubs. It is important to directly address gender norms and to include girls and boys.

    Local officials should be supported to raise awareness of the criminalisation of FGM

    The value of fines should be considered on a community-by-community basis, to ensure that they are not forcing practices underground

    In communities where girls ‘choose’ to undergo FGM/C, it is important to pair awareness-raising efforts with exposure to role models or champions for eliminating the practice, to counter the weight of peer pressure.

    Expanded efforts should be made to trial whether and under what circumstances efforts to expand the livelihoods of traditional circumcisers might reduce the pressure that older, respected women in the community are able to levy on mothers – and ultimately reduce FGM/C.

    The government and its partners should engage with healthcare providers

    Healthcare providers – including health extension workers – should receive iterative training that emphasises how FGM/C violates the medical code (to keep it from becoming medicalised), also ensuring that girls and women who have undergone FGM/C are not stigmatised or blamed for having been cut – even when it causes medical complications.

    Actors must adopt a long-term lens to programming, recognising that social norm change processes are non-linear

    It is vital to recognise that because FGM/C has been widely practised across Ethiopia for millennia, eliminating it will take continuous pressure over time. To prevent resurgence, it is important to acknowledge that even when most people believe the practice has been eradicated, there will be pockets of resistance that could lead to its re-emergence if education and enforcement efforts weaken.

    Given the diverse ways in which FGM/C is practised even with a single zone, it is important to assess progress through regular community-based monitoring exercises aimed at tracking both its incidence and type(s), and how practices might be shifting to make them less visible.